Pulmonary Medicine is a branch of medicine that deals with respiratory diseases, chest wall diseases, sleep disorders, allergy and much more. This presentation describes this specialty branch in detail with scope and current perspectives being emphasized. It will help in PG aspirant medicos, academicians and undergraduate students to know about Pulmonary Medicine in detail.

1. Pulmonary Medicine
Scope & Future
An Indian Perspective
Dr. Jebin Abraham MD
Department of Pulmonary Medicine
Government Medical College Patiala

2. Preface
 This article is emphasising Pulmonary Medicine as a specialty branch.
 A guide to medical undergraduates, PG asprants and postgraduate
students.
 Current and future perspectives of Pulmonary Medicine is explored in
Indian medical scenario.
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3. Introduction
 Pulmonary Medicine deals with diseases of lungs, airways, chest wall,
sleep disorders as well as allergy.
 It is an evolving medical branch with advanced subspecialties.
 Also Known as
Respiratory Medicine
Chest diseases and Tuberculosis
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4. Introduction
 Initially started as a specialty branch to deal with tuberculosis, the age old
menace in Indian community.
 Apart from tuberculosis, it deals with all sorts of respiratory diseases and
provides expertise in various diagnostic and therapeutic procedures.
 Currently being recognized as a super-specialty branch.
 Available degrees/diplomas: MD, DNB, DTCD, DM
 Seats are limited compared to General Medicine and Paediatrics.
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5. Do you fit for Pulmo?
 Do you wish to be a physician?
 Do you want end-specialty (more or less)?
 Do you wish to avoid heavy duties?
 Do you wish to spend enough time with your family?
 Do you wish to avoid medico-legal issues?
 Do you like minor surgeries?
 Do you wish to use a Bronchoscope/ Thoracoscope?
Well, go for Pulmonary Medicine.
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6.  If you want to work like a super-specialist but not ready to spend 3 more
years in study…
 If you want to be a physician but not ready to have a hectic PG life…
 If you want an end specialty but not interested to have a ‘do or die’
struggle in PG entrance test…
 Then, go for Pulmonary Medicine.
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7. Disease Spectrum of Pulmonologist
 Tuberculosis & Drug Resistant TB
 Asthma and Allergy
 COPD
 ILD
 Bronchiectasis
 Pneumonia
 Hypersensitivity pneumonitis
 Occupational Lung Diseases
 Pleural effusion
 Pneumothorax
 Lung Cancer
 ARDS
 Sepsis
 …………
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8. Skills to Master
 Clinical Examination
 Chest X ray/ CT Scan interpretation
 Pulmonary Function Tests
 Body Plethysmography
 DLCO
 Pleural Tap
 Pleurodesis
 Pleural Biopsy
 Tube Thoracostomy
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9. Skills to Master
 ECG
 ABG interpretation
 Non invasive ventilation
 Mechanical Ventilation
 Central vein Catheterisation
 Cardiopulmonary Resuscitation
 Pulmonary Rehabilitation
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10. Skills to Master
 Allergy Testing & Immunotherapy
 Polysomnography
 FNAC
 CT Guided FNAC/Biopsy
 Bronchoscopic procedures: BAL, TBLB, TBNA, Bronchial wash, Foreign
body removal..etc.
 Thoracoscopy
 Thoracic Ultrasound
 Advanced : Stenting, Argon Plasma Coagulation/Laser therapy,
Cryobiopsy, EBUS, Bronchial Thermoplasty…
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11. Sub-specialties
If you wish to explore further after MD/DNB Pulmo, you may go for
fellowship/training/diploma for various sub-specialties:
 Allergy and Asthma
 Sleep Medicine
 ICU and Critical care
 Interventional Pulmonology
 Medical Research
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12. What after MD?
 Start your own clinical practice
 Join as Medical College faculty
 Join for DM - Reach the top of specialty
 Concentrate on any of sub-specialties
 Do research and contribute to science
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13. Courses after MD
 DM in Pulmonology, Critical care, Cardiology, Infectious disease
 Fellowships/Diploma in Sleep Medicine (FSM), Intensive care (IDCCM),
Allergy and Asthma (DAA), Interventional Pulmonology etc
 Others: Thoracic oncology, Paediatric pulmonology, Public health
 Also FCCP, FIAB, FNCCP etc.. etc..
 Training Courses/ Workshops: EBUS, Thoracoscopy, Interventional
Pulmonology, ICU Management, Mechanical Ventilation, Allergy testing
and Immunotherapy, Sleep Medicine, Thoracic ultrasound etc.
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14. Allergy and Asthma
 Most demanding specialty
 Yet under-explored area
 Easy practice
 Low infrastructure requirement
 Good outcome
After all, just look around for an allergist…. Do you find anyone?
If no, then why shouldn’t you place yourself there?
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15. Sleep Medicine
 A growing specialty
 Under-explored in India
 Demand increasing rapidly
 Life-style diseases and sleep disorders are raising together in India
 No substitute for a sleep physician
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16. ICU and Critical care
Pros
 Every good hospital requires intensivists: Good scope
 Fellowships and diplomas available
 Good earnings
 No long term responsibilities
 Highly skilled area
Cons
 Heavy duties
 Rapid decision making
 No social life
 Poor long term doctor-patient relationships
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17. Interventional Pulmonology
Pros
 Highly skilled specialty
 Less competition
 Professional competency and satisfaction
 Good earning
Cons
 High infrastructure setups
 Sturdy training
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18. Medical Education & Research
Pros
 Contributing to Medical Science
 High position in medical society
 Top academic position
 Draft national and international guidelines
 Work with international societies, eg WHO
 Teach upcoming generation of doctors
Cons
 Slow career growth
 Low initial financial benefit
 Government restrictions on private practice
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19. General Medicine Vs Pulmonary
Medicine
General Medicine
Pros
 Enables you to diagnose and treat a variety of systemic diseases.
 Vast diagnostic check ups and diverse case scenarios.
 Able to provide basic medical support to all age groups.
 Independent practice possible
 Can adapt to small and large hospitals
Cons
 Trend of super-specialty seeking is increasing
 Tight competition among peers
 Require referral to super-specialty sections often
 Do not promise deep knowledge about any single system
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20. General Medicine Vs Pulmonary
Medicine
Pulmonary Medicine
Pros
 Deep knowledge about subject ( At least, textbook Fishman (Pulmo) is
heavier than Harrison’s !)
 Super-specialist care at specialist level (eg. Bronchoscopy and
Thoracoscopy)
 No hectic duties
 Equal pay
 Limited but relevant cases
 Able to provide critical care
 Highly skilled procedures like EBUS-TBNA and other interventions
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21. General Medicine Vs Pulmonary
Medicine
Pulmonary Medicine
Cons
 Lack of training in internal medicine
 Possible difficulty in managing multi-systemic diseases
 Risk of occupational hazard- MDR TB and Viral infections
 Lack of popularity of branch among public
 Lack of specialist post/vacancy: Many govt as well as private hospitals does
not accommodate separate pulmo dept.
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22. MD Vs DNB
 Both are well recognized.
 MD is more popular than DNB among public.
 Medical colleges offer more academics than private hospitals (Of course,
there are exceptions!)
 MD holder can appear for DNB exam and obtain an additional degree
 MD course provide better research facilities
 DNB course provide better exposure to latest equipment and advanced
treatment options
 MD has higher case load
 MD holder can directly enter medical education services
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23. Scope of DM Pulmonology
 Opportunity to become pioneers in the specialty
 Less number of seats
 Work experience from top rated institutes
 Opportunity to try out most recent advances in the field
 Good professional skills and gains
 A step to become recognized international level faculty
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24. Scope of Pulmonary Medicine in
General Practice
 Well… What is the most common symptom with which patients come to
general OPD?
 Yeah….. Its Cough!!
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25. Important facts
 Your attitude matters more than your skills, whatever be your degree.
 Success depends on how you define it, not simply on your bank balance.
 Select a good institute to join. DNB from a good institute might be practically
more valuable than MD from a bad institute.
 Give importance to your personal and family life while opting for a college far
away from your home. And of course, language and food!
 Be aware about current status of bond.
 Try to contact current PG students working in the institute you wish to join.
Enquire about the duties, academics, casual leaves etc. Be sure that your future
Head should not be a ‘head eater’!
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26. An Ideal Training Institute
 Spirometry
 Body Plethysmography
 DLCO
 Basic Bronchoscopy Suite (BAL, TBLB, TBNA)
 Thoracoscopy
 Sleep Lab
 Respiratory ICU
 Non invasive Ventilation
 Mechanical Ventilation
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27. An Ideal Training Institute
Preferable to have:
 Higher number of recognized PG seats
 Good patient load
 Specialty posting in other departments
 Good stipend and No bond
 Night duty offs
 More Casual leaves
 Academic programs: Seminars, Journal Clubs, Bed-side Clinics, Conferences,
Workshops
 After all, you need a good HOD and Unit Head!
Enquire about all these things before you opt in.
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28. FAQ
Q) I wanted General Medicine. But my rank is not good enough to get
it. Shall I take one more chance or opt for Pulmonary Medicine?
 Well, you might have got the answer by now. Number of PG aspirants are
exponentially increasing every year. So definitely you need to improve your
efficiency in next attempt. Getting a better rank depends on your
commitment and smart work (? Hard work). Nothing is impossible. But be
intelligent in taking decisions. Your entire career depends on what you
choose.
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29. FAQ
Q) Is there a risk of acquiring TB while doing PG in Pulmonary Medicine?
 Yes, definitely a risk is there. But this risk is there for every doctor. Before a TB
patient present to a pulmonologist, he would have consulted at least one
general practitioner for his cough. So who is at higher risk?
 Being a chest physician, you will be trained how to protect yourself from TB by
simple precautions and believe me, you will be suspecting TB in every possible
patient.
 TB is a curable disease.
 Surgeons are at risk of HIV/HCV. Won’t they do surgeries? Risks are there
everywhere.
 Residents in Surgery, Medicine and even Gyne do get TB. Why? Stress and
workload, dietary habits and lack of precautions.
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30. FAQ
Q) MD Pulmonary medicine and MD TB & Chest… Are they same?
 Yes. TB and Chest was old name of the degree, and still frequently used in
north India. However, most of the universities are awarding the degree as
MD Pulmonary Medicine.
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31. FAQ
Q) Can I confidently work in ICU/Critical care after doing MD Pulmo?
 It depends purely on your training. If you take degree from a good institute
where you are getting exposure in ICU care, you may straight away work in ICU
after your course.
 However, majority of colleges offer only respiratory ICU training, if at all; Many
lack ICU also.
 You may undergo short term training in any good institute for critical care.
 Or, do courses like IDCCM or fellowships which are getting good opportunities
currently.
 Or, go for DM.
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32. FAQ
Q) What is the scope of MD/DNB outside India?
 Good scope, as similar to other medical branches.
 Recognition of degree depends on individual country’s policies.
 One can seek relevant fellowships in foreign countries as well.
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33. FAQ
Q) Which are the recommended textbooks for Pulmonary Medicine?
 You have to follow one standard textbook throughout your course. But you
have to depend on other books also for reading selected topics.
 Well, I will go for Fishman. It is vast and authentic. But not an exam friendly
style. Make notes while reading Fishman. This book will teach you concepts.
High yield topics : Sleep and disorder, Lung and other systems, ILD, Respiratory failure,
Oxygen therapy, Diagnostics, Occupational diseases, Cancer basics & Obstructive airway
diseases.
 Murray and Nadal: Standard textbook. Can be considered as alternative to
Fishman. Selected topics may be read from Murray even when following
Fishman.
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34. FAQ
 Crofton: Basic topics (Eg- Bronchiectasis) are well explained. But not an
updated book for advanced topics. So selective reading is advised.
 SK Jindal: Student friendly, exam oriented, Indian authored book, vast
coverage including critical care.
High yield topics : All topics (leftover) can be quickly read is the biggest
advantage, Sepsis , Critical care & Aging.
 Washington Manual of Pulmo Med: Pocket book, good for fast reading.
Not all topics included.
 Lights (Pleural diseases): Must read, basic textbook
High yield topics : Physiology , Transudative PE, Tubercular, Parapneumonic PE,
Malignant PE, Pleural Malignancy, Hemo/Pneumo/ChyloThorax
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35. FAQ
 Zumla: Standard textbook for TB
High yield topics : General and Basic TB (TB pathogenesis , HIV and TB)
 Sharma and Mohan: Good for TB, Alternative to Zumla
High yield topics : NTM, Systemic tuberculosis
 Tomans: Must read book for TB
High yield topics :TB basics (diagnostic and treatment basics)
 Pulmonary/Respiratory therapy Secrets: A must read book during PG
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36. FAQ
 Felson (Chest Roentgenology): Extensive coverage of Chest X Ray. Not for
exam oriented reading.
 CXR- Survival guide: For exam oriented reading.
 Webb (HRCT): Good one.
 West : High yield for pulmonary physiology
 Handbooks on ECG, Spirometry etc
 Hutchison/Mcleods: Standard clinical examination texts, to learn how to
examine a patient
 Alagappan/Golwala/Baburaj: For clinical viva and DDs
 Kundu: For case discussion
 CMDT/Harrison: To keep in touch with other systems. They give edge in
competitive exams
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37. FAQ
 Interesting reads (add on):
 ICU book : Paul Marino
 Ventilator : Chang
 Bronchoscopy book
 Allergy: Middleton’s
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38. Journals to subscribe
 An extensive list of journals are available on Respiratory Medicine.
 Most of them provides E mail subscriptions free of cost.
 Some Journals:
Chest, Thorax, Lancet, European respiratory journal, AJRCC etc.
Indian: Lung India, Indian Journal of Tuberculosis, Indian Journal of
Chest Diseases and Allied Sciences, Indian Journal of Allergy Asthma and
Immunology etc.
 A list of top journals are available at:
https://www.scimagojr.com/journalrank.php?category=2740
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39. Practice Guidelines
 TB : TOG -2016, 2019 updates ; PMDT-2017, BDQ/DLM-2018 , INDEX TB
 ILD: 2011/2018 IPF
 CA: NCCN 2018
 Asthma: GINA 2019 ( and changes from last guidelines)
 COPD: GOLD 2019 ( and changes from last guidelines)
 Spirometry guidelines 2019 (Indian)
 CAP / HAP – Indian guidelines -2011
 Survival Sepsis Campaign 2018
 BTS guidelines for Inhaler use and Bronchoscopy.
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40. Major Conferences
 Chest Annual Meeting
 ERS Annual Meeting
 ATS Annual Meeting
 NAPCON
 NATCON
 BRONCHOCON
 ICAAICON
 Pulmonary Medicine Updates
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41. FAQ
Q) Can/ Shall I join any professional organizations while doing PG?
 Yes. You can join various medical and specialty organizations and enhance
your professional network.
 ACCP, ERS, Indian Chest Society, NCCP etc are some of the professional
networks.
 IMA membership is also helpful in career.
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42. FAQ
Q) How to become FCCP?
 FCCP is a honorary fellowship, which requires specified criteria as explained
in ACCP website. For that you need to be a member of ACCP at least for 2
years, along with other professional contributions and recommendations.
 ACCP membership is open to PG students also. So you can apply for it
soon after joining your PG and later for FCCP.
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43. Selecting A Thesis Topic
 Thesis is a scientific research work done under careful supervision of senior
faculty of the department.
 Novel topics are always highly recommended, however execution of the
research work should be prime concern (Just think whether you will be
able to perform the work under your current circumstances with available
resources).
 Think twice while selecting dynamic topics (Those which might be
influenced by changing health policies or guidelines in coming years: It
might reduce relevance of your research at the time of publication, Eg-
RNTCP Category 2.
 Even if you get no positive correlation or statistical significance, your study
will be scientifically significant, if done in proper way.
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44. Selecting A Thesis Topic
So, while selecting a topic, consider these points
 Is it a relevant topic?
 Will it contribute something new to science?
 Do you have the necessary facilities in your department?
 Will you get enough support from your department?
 Do your supervisor completely agree for this project?
 Is there a concern of financial needs?
 Will you get support from other departments (If your requires)?
 Will you get ethics committee approval?
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45. Selecting A Thesis Topic
 Repeating a topic already done many times will make it easy for you as
you can get help from previously done thesis works.
 However, on a scientific aspect, it would not help you in career growth.
 Doing thesis on a new subject is interesting and challenging. However,
your resources will be limited. But, results will be rewarding.
 Make sure that topic is cost effective for your patients and meet ethical
standards (Get help from supervisor).
 Cross sectional and retrospective studies are easy to perform. However,
their research value is low while getting published.
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46. Selecting A Thesis Topic
 Interventional studies and clinical trials are difficult to carry out. However,
they have high research value.
 Go through national conference booklets (NAPCON, NATCON) and
journals for current trending topics.
 Make sure your topic abides university rules (Like, it should not have been
conducted in previous 5 yrs in your college/ university etc).
 Try to obtain grants/ financial assistance available for young researchers.
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47. Selecting A Thesis Topic
 Pre-plan how you will construct your master-chart and what all parameters
will be taken for stats (It will help you later!): Get help from seniors.
 Conduct parallel researches along with thesis on related/extended topic: It
can help you to furnish an extra paper.
 Finish the thesis work during initial months of final year and get enough
time for exam preparation.
 Present your paper in National / International conference and publish it in
peer reviewed indexed journals.
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48. Case Presentation Proforma for
Respiratory System
Available at: https://dx.doi.org/10.13140/RG.2.2.25781.22243
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49. Thank You
Dr. Jebin Abraham, MD
Email: drjebin@allergist.com
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Hope this article would have helped you out in some aspects.
Being a rapidly evolving branch, knowledge and practice of
Pulmonary Medicine is getting updated everyday. For opinions
and suggestions regarding the topics discussed in this piece of
work, subject experts, academicians and medical students are
welcomed to contact the author.
©Author
07-07-2019